A Dissertation entitled Relations between PTSD and Distress Dimensions in an Indian Child/Adolescent Sample following the 2008 Mumbai Terrorist Attacks by Ateka A. Contractor Submitted to the Graduate Faculty as partial fulfillment of the requirements for the Doctor of Philosophy Degree in Clinical Psychology _________________________________________ Jon D. Elhai, PhD., Committee Chair _________________________________________ Andrew L. Geers, PhD., Committee Member _________________________________________ Joseph D. Hovey, PhD., Committee Member _________________________________________ Marijo B. Tamburrino, M.D., Committee Member _________________________________________ Mojisola F. Tiamiyu, PhD., Committee Member _________________________________________ Patricia R. Komuniecki, PhD, Dean College of Graduate Studies The University of Toledo August 2015 Copyright 2015, Ateka Akbar Contractor This document is copyrighted material. Under copyright law, no parts of this document may be reproduced without the expressed permission of the author. An Abstract of Relations between PTSD and Distress Dimensions in an Indian Child/Adolescent Sample following the 2008 Mumbai Terrorist Attacks by Ateka A. Contractor Submitted to the Graduate Faculty as partial fulfillment of the requirements for the Doctor of Philosophy Degree in Clinical Psychology The University of Toledo August 2015 Posttraumatic stress disorder’s (PTSD) four-factor dysphoria model (Simms, 2010) has substantial empirical support (reviewed in Elhai & Palmieri, 2011; Yufik & Simms, 2010). However, debatable is whether the model’s dysphoria factor adequately captures all of PTSD’s general emotional distress (e.g., G. N. Marshall, Schell, & Miles, 2010; Miller et al., 2010). Thus, the present study assessed the factor-level relationship between PTSD and general emotional distress to answer two research questions: 1) Relative to other PTSD factors, does the dysphoria factor better account for variance in external measures of emotional distress?, and 2) which emotional distress dimension is most related to PTSD’s dysphoria factor (related to PTSD’s placement in the quadripartite model)? The relevance of the current study is further enhanced by virtue of using a young Eastern cultural sample (i.e., India) with exposure to terrorist attacks. Data analyses was conducted on an archival dataset collected by Mithibai College at Mumbai, comprising of children and adolescents attending school during and in the vicinity of the 2008 Mumbai terrorist attacks. PTSD and emotional distress were measured by the UCLA PTSD Reaction Index (PTSD-RI; Steinberg, Brymer, Decker, & Pynoos, 2004) and the Brief Symptom Inventory-18 (BSI-18; Derogatis, 2001) respectively. Primary analyses entailed iii confirmatory factor analyses (CFA) to assess the hypothesized PTSD and BSI-18 model fit, followed by Wald tests of parameter constraints to assess hypothesized relations between PTSD’s and BSI-18’s latent factors. Specifically, I assessed if BSI-18’s somatization (Hypothesis 1), anxiety (Hypothesis 2), and depression factors (Hypothesis 3) related more to PTSD’s dysphoria than other PTSD factors. Further, I assessed if PTSD’s dysphoria related more to BSI-18’s somatization than BSI-18’s depression (Hypothesis 4) and anxiety factors (Hypothesis 6), and more to BSI-18’s depression than to its anxiety factor (Hypothesis 5). Significant results indicated that BSI-18’s depression and somatization factors related more to PTSD’s dysphoria factor than PTSD’s avoidance factor. Additionally, PTSD’s dysphoria factor related more to BSI-18’s depression than BSI-18’s anxiety and somatization factors. Consequent implications are discussed in detail. iv Acknowledgements I would like to express my deepest gratitude to Dr. Jon Elhai for his critical feedback, guidance, patience, and support provided to pursue my research. His confidence in my ability to undertake and complete my dissertation amidst challenges inherent in using data from another country and to explore novel ideas has been instrumental. I am truly grateful for his mentorship. I further appreciate the feedback from my committee members on my dissertation project. I am grateful to Ms. Panna Mehta and her students for their collaborative efforts in data collection and data entry. Most importantly, I would like to thank my parents, brother, husband and close friends for being my strength throughout this process with immense confidence in my ability to accomplish my academic goals. Their optimism and emotional support has been of utmost importance and value and I am unable to envision achieving my goals without them. v Table of Contents Abstract............................................................................................................................... iii Acknowledgements………………………………………………………………………..v Table of Contents…………………………………………………………………………vi List of Tables……………………………………………………………………………...ix List of Figures……………………………………………………………………………..x List of Abbreviations……………………………………………………………………..xi List of Symbols………………………………………………………………………….xiii I. Introduction…………………………………………………………………………….1 A. PTSD in Children and Adolescents…………………………………………...1 B. Underlying Dimensions of PTSD……………………………………………..4 C. Underlying Dimensions of Emotional Distress………………………………..8 D. PTSD and Emotional Distress…………………………………………………9 E. Relation between PTSD’s Dysphoria and BSI-18’s Emotional Distress Factors………………………………………………………..…………………..12 F. The 2008 Mumbai Terrorist Attacks…………………………………………14 G. The Indian Cultural Context…………………………………………………17 H. Current Study………………………………………………………………...22 I. Significance…………………………………………………………………...25 a. Theoretical…………………………………………………………...25 b. Clinical……………………………………………………………….26 c. Statistical……………………………………………………………..27 II. Method…………………………………………………………………………….....28 vi B. Participants/Procedure……………………………………………………….28 C. Instrumentation………………………………………………………………29 a. Demographic information……………………………………………29 b. Experience with the 2008 Mumbai terrorist attacks…………………29 c. Traumatic events……………………………………………………..30 d. Brief Symptom Inventory-18 (BSI-18)………………………………30 e. The UCLA PTSD Reaction Index (PTSD-RI)……………………….31 D. Exclusions and Treatment of Missing Data………………………………….32 E. Analysis……………………………………………………………………....34 a. CFA…………………………………………………………………..34 b. Wald chi-square tests of parameter constraints……………………...39 III. Results……………………………………………………………………………….40 A. Exclusions and Treatment of Missing Data………………………………….40 B. Effective Sample Characteristics…………………………………………….40 C. Primary analyses……………………………………………………………..46 a. CFA…………………………………………………………………..46 b. Wald chi-square tests of parameter constraints……………………...48 IV. Discussion…………………………………………………………………………...53 A. Does Dysphoria Account for PTSD’s General Emotional Distress?....................54 a. Somatization……………………………………………………………..54 b. Anxiety…………………………………………………………………...56 c. Depression………………………………………………………………..57 vii B. Which Component of Emotional Distress has the Greatest Association with PTSD’s Dysphoria?...............................................................................................58 C. Implications………………………………………………………………………60 a. Theoretical……………………………………………………………….60 b. Clinical…………………………………………………………………...65 c. Statistical…………………………………………………………………66 D. Limitations and Future Research………………………………………………...67 E. Conclusion……………………………………………………………………….69 References………………………………………………………………………………..71 viii List of Tables Table 1 Three and Four-Factor PTSD Models................................................................7 Table 2. Demographic Information of 818 Participants……………………………...42 Table 3. Information on Direct and Indirect Exposure, and Reactions to the Terrorist Attack Event……………………………………………………………………………...43 Table 4. Exposure to Other Potentially Traumatic and Problematic Events…………45 Table 5. Standardized Factor Loadings of the PTSD-RI Items per the Dysphoria Model……………………………………………………………………………………47 Table 6. Standardized Factor Loadings of the BSI-18 Items per BSI-18’s Three Factor Inter-correlated Model…………………………………………………………………...48 Table 7. Results of the Wald Tests of Parameter Constraints………………………...51 Table 8. Patterns of Correlations between PTSD and Distress Factors………………52 ix List of Figures Figure 1 Item mappings of the PTSD dysphoria model using the PTSD-RI items….35 Figure 2 Item mappings of the BSI-18 three-factor inter-correlated model…………36 x List of Abbreviations BAI .............................Beck Anxiety Inventory BDI .............................Beck Depression Inventory BIC .............................Bayesian Information Criteria BSI-18………………Brief Symptom Inventory–18 CFA ............................Confirmatory Factor Analysis CFI .............................Comparative Fit Index DF…………………. .Degrees of Freedom DSM-IV .....................Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition DSM-5……………... Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition EFA ............................Exploratory Factor Analysis GSI .............................Global Severity Index ICD-10 ……………..International Classification of Disease-10 MAR ..........................Missing At Random MCAR ........................Missing Completely at Random MI ...............................Multiple Imputation ML..............................Maximum Likelihood MLM ..........................Maximum Likelihood with a mean-adjusted chi-square MMPI-2......................Minnesota Multiphasic Inventory-2 MNAR........................Missing